Archivi delle etichette: Quality Improvement

I named this blog “Losing Patients” as a play on words. But in all seriousness, our health care system is literally losing “patients,” killing more than 500 per day from errors, accidents and infections in hospitals alone, not to mention the mortality and suffering from millions of procedures that never needed to be done in the first place. At the same time, the employers and other purchasers paying for this care are losing “patience” with the slow pace of change in cleaning up the mess.

Think I’m a bit too pessimistic? Take the example of early elective deliveries. These are births scheduled without a medical reason between 37 and 39 completed weeks of pregnancy. The prevalence of these unsafe deliveries perfectly embodies the five biggest problems in our health system. Below I explain how — but keep reading, because I do have some words of optimism in the end.

Problem 1: Too Much Unnecessary Care

Overuse and unnecessary care accounts for anywhere from one-third to one-half of all health care costs, which equal hundreds of billions of dollars, in addition to the half-a-trillion per year experts attribute to lost productivity and disability.

Early elective deliveries are unnecessary, according to advice by the American College of Obstetricians and Gynecologists, that has been repeated for more than 30 years (that’s not a typo – 30 years), a point reinforced today at a press conference. This is a message carried by several other highly respected organizations like Childbirth Connection, the March of Dimes and the Association of Women’s Health, Obstetric & Neonatal Nurses (AWHONN). All national health plans concur. Nonetheless, we saw a dramatic escalation in the rates of these deliveries from the 1990s to the first decade of the new century.

Problem 2: Avoidable Harm to Patients

This is one of health care’s most common problems. The statistics are staggering. Here’s an example: one in four Medicare beneficiaries that are admitted to a hospital suffers some form of harm during their stay. Would you get in your car if you thought you had a one in four chance of harm during the drive?

Early elective deliveries harm women and newborns. Babies born at 37-39 completed weeks gestation are at much higher risk of death. They are also at a far higher risk for harms like respiratory problems and admission to the (NICU).

A report by the Institute of Medicine Health suggests a third or more of health costs are wasted. The cost of these unnecessary, harmful early elective deliveries was estimated in a study in the American Journal of Obstetrics and Gynecology to be nearly $1 billion per year.

Problem 4: Perverse Incentives in How We Pay for Care

Traditionally, health plans, Medicare and Medicaid pay providers for whatever services they deliver, regardless of whether the service truly benefits the patient. As an excellent new book called “The Incentive Cure” points out (as does a plethora of other literature that could fill several libraries), how we end up with an epidemic of perverse incentives.

The harsh truth about early elective deliveries is that our payment system encourages them. They generate admissions to NICUs, and NICUs are profit centers. Studies suggest that reducing the rate of these deliveries to a reasonable number could eliminate as many as one-half million NICU days, which could lower health costs for the U.S. But this would force hospitals to take a big financial hit. To their credit, in my experience, once hospitals recognize they have a problem with early elective deliveries, they don’t think twice about taking that hit. States like South Carolina and Texas are trying to reverse the incentives, as are many employers. Unfortunately, they are the exception that proves the terrible rule of insane payment incentives.

Problem 5: Lack of Transparency

We have far more information available to us to compare and select a new car than we do to choose where to go for lifesaving health care.

Transparency galvanizes change like nothing else. Early elective deliveries exemplify that: Despite warnings over the years from medical societies and highly respected national organizations, the rates of these deliveries have been rising for decades. That stopped when a purchaser-driven organization, The Leapfrog Group (my organization), started reporting early elective delivery rates by hospitals in 2010. Suddenly, the rates started declining. Just today, Leapfrog released the 2012 data showing that the national rate for early elective deliveries is 11.2 percent, down from 17 percent in 2010. This is a voluntary survey, with nearly 800 hospitals providing the data willingly. Consumers deserve to know these rates for every hospital delivering babies in the country.

Now for a Dose of Optimism

We have a glimpse of success in ending early elective deliveries. Sparked by public reporting, we have seen a growing cadre of providers, policymakers and consumer advocates uniting to address this problem, and the Department of Health & Human Services declared early elective deliveries as a top priority issue. Regional coalitions are also vowing to end the practice in their community.

The next step is for purchasers and consumers to keep up the pressure because that will only help in encouraging real change. And we need to apply that model across the board – the business community should also work together to address the five big problems in health care that have a direct impact on their own employees’ health and their business’ bottom line. The key message here for all groups is this: don’t financially reward the wrong care and demand transparency.

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

Identifying high-risk patients early

Educating the patient and involving family members

Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Background

Social inequalities in health are a characteristic of almost all European Welfare States. It has been estimated, that this is associated with annual costs that amount to approximately 9% of total member state GDP. We investigated the influence of inequalities in German health care utilization on direct medical costs.

Methods

We used longitudinal data from a representative panel study (German Socio-Economic Panel Study) covering 1994 to 2010. The sample consisted of respondents aged 18 years or older. We used additional data from the German Health Interview and Examination Survey for Children and Adolescents, conducted between 2003 and 2006, to report utilization for male and female participants aged from 0 to 17 years. We analyzed inequalities in health care using negative binomial regression models and top-down cost estimates.

Results

Men in the lowest income group (less than 60% of median income) had a 1.3-fold (95% CI: 1.2-1.4) increased number of doctor visits and a 2.2-fold (95% CI: 1.9-2.6) increased number of hospital days per year, when compared with the highest income group; the corresponding differences were 1.1 (95% CI: 1.0-1.1) and 1.3 (95% CI: 1.2-1.5) for women. Depending on the underlying scenario used, direct costs for health care due to health inequalities were increased by approximately 2 billion to 25 billion euros per year. The best case scenario (the whole population is as healthy and uses an equivalent amount of resources as the well-off) would have hypothetically reduced the costs of health care by 16 to 25 billion euros per year.

Conclusions

Our findings indicate that inequalities and inequities in health care utilization exist in Germany, with respect to income position, and are associated with considerable direct costs. Additional research is needed to analyze the indirect costs of health inequalities and to replicate the current findings using different methodologies.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits. It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving? Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

A huge number of people who work in offices are not paid to dig ditches or split logs, so if they are not paid for their brawn they must be paid for their brain?Apparently not.

People who work in command and control organisations, despite their best intentions, if they want to survive and thrive are mainly paid for the following, check which or these attributes YOU have and which you have to build on.

The ideal command and control candidate for the top:

decisive. i.e .do you make decisions very quickly indeed.The shorter the gap between being presented with a need for a decision and the decision coming out your mouth, the more decisive you are.

does an awful lot. The more you do, the better value you are. Everyone knows that there is only one thing worse than doing the wrong thing right, and that is not doing enough of it.

walks places very fast. Upping the pace of a walk to a fast stride is just the beginning of a meteoric career path. You need speed to ensure dynamism. The older you get, the greater the need to gallop down corridors to maintain your aura of urgency.

delivers. If you make snap decisions, do a lot of rubbish and run down corridors , it is all for naught unless you deliver. Doesn’t matter what you deliver, as long as you do. Like a postman with a heavy round at Christmas, what is IN those parcels is irrelevant, just get delivering.

has a lot of staff. The more you have, the more important you are. You must be, otherwise why would you have all those staff?

positive. Are you positive that your boss is right? Then by agreeing with him (it’s a him, you read point 6 right?) so are you! Handy!

has a good team of staff who agree with you. If your staff agreed with you less, they would be in charge. And you are in charge, so therefore see point 7.

maintains good relationships. The currency is popularity. Popularity among others above and alongside you. But don’t be too popular. That way lies flavour of the month, and last month was December. Don’t be a January because February comes round soon enough.

None of these attributes for success will be improved by thinking or the consequence of thinking, learning. In fact the opposite is true. If you think, you have to slow down and stop being so decisive [point 1], you might stop doing an awful lot, as most of it might turn to be rubbish [point 2]. You might find that your boss is wrong [point 7], or even worse, that you are. You might start to find that it spreads, and that your team start thinking too [point 8] and then where would you be?

It is important to recognise that learning and thinking are just code-words for self-doubt and lack of confidence. Avoid them at all costs!

EDIT this post originally came out over a year ago, and I took it down from public view during one of the 4 restructures since November 2011. Now times are saner, this blog was referenced on my last application form I filled in for my own job, and the content and style went down well with the first manager I’ve had in the organisation who didn’t treat me as a problem but as an opportunity, and wants to see what we can do publicly and officially with systems thinking and all that. Hence this post resurfacing like an rusty abandoned shopping trolley in a dank park lake. And John Seddon commented on it, which pleased me no end.
Bring on the mucky faced lad!

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these “potentially or probably inappropriate” procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

“We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines,” says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, “procedures were repeated too soon after a negative exam,” increasing the odds of avoidable harm, such as “perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events,” she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force’s prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

“For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines,” she says. “So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults,” Sheffield said.

Her report, published in this week’s JAMA Internal Medicine,looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a “potentially or probably inappropriate” colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

“Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

“For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule.”

And if that were the case, there wouldn’t be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and “a moral obligation.”

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, “would be the same as me taking my life. And that’s a sin.”

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn’t be screened was made only to save money.

“Public health education and physician endorsements (of cancer screening) may have created a high degree of ‘momentum’ for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens.”

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

“Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult’s lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment.”

She blames “unbalanced public health messages” for contributing to “perceptions that cancer screening should be continued indefinitely,” she also points to the physician’s recommendation as a strong driver of whether a senior citizen undergoes one.

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

The president of Partners Healthcare and a Harvard University economist contend that primary care in the U.S. needs to be restructured to improve physician business practices and provide more value for patients.Under this “subgroup management,” primary care physicians would oversee improved coordination of care for greater efficiencies and clinical outcomes.

So say Thomas H. Lee, MD, network president of Partners Healthcare, and Michael E. Porter, PhD, the Bishop William Lawrence University Professor at the Harvard Business School, and director of The Institute for Strategy and Competitiveness, both in Boston, in a Health Affairsarticle this month. I spoke to both of them about their primary care challenge. (Erika Pabo, MD, MBA, a resident at Brigham and Women’s Hospital in Boston, was a co-author.)

“If we’re going to make primary care as effective as we want to, we have to start with a clear overreaching goal and try to restructure primary care,” Porter says. “It starts with value and that’s the true north compass. Primary care isn’t really one thing. It’s a lot of different things for a lot of different patients with very different needs.”

“If we can segment the needs and take patients and group them into fairly straightforward categories, such as healthy adults, or someone with one or two chronic conditions or very disabled people, we can understand the needs of a defined group of patients, and change the nature of primary care,” Porter adds.

The primary care framework isn’t working now, they say. As Lee sees it, too many physicians are “stumbling down a road, not sure where they are trying to go, as opposed to a bunch of people effectively moving down a road.” For doctors, it’s a vital question: their livelihoods are at stake.

“Market share is going to places that can meet patients’ needs and do it more effectively,” Lee says. He warns that physicians who “won’t be able to get their act together to adopt a strategic framework will be less successful and lose market share to organizations that can.”

Under their plan, a physician practice would divide patients into small groups reflective of differences of “core needs and circumstance,” Porter and Lee write. A practice may refer some patients to other providers better equipped to meet particular needs.

As it is now, an absence of a “robust overall strategy” is one of the causes of primary care’s problems, according to Porter and Lee.

“Thinking about primary care as a single service not only undermines value but also creates a trap that makes value improvement difficult, if not impossible. We will never solve the problem by trying to do primary care better,” they write. “Instead, primary care must be redefined, deconstructing the work that goes on within those practices and rethinking how it is performed.”

Examples of the team focus: integrated cancer teams that increasingly include both palliative care specialists and a psychiatrist to measure patient outcomes. Or, patients with end-stage renal disease may be referred to a dialysis team that provides primary as well as nephrology care.

As Porter and Lee envision a new primary care structure, they say care teams and delivery processes can be designed for each patient subgroup, with measurable outcomes. Such data measurement is woefully lacking under current primary care, they say.

The possible changes would touch not only on clinical care, but also go into the day-to-day function of existing primary care practices, which includes scheduling or patient visits. Patients with common chronic diseases can be “preferentially” scheduled to facilitate more efficient visits that may include group educational programs, they write.

Diabetes sessions could include an expansive team of specialists such as endocrinologists, podiatrists, and nephrologists. Especially complex case sessions with patients could involve mental health specialists, palliative care consultants, and social workers.

It’s no surprise, they say, that some of the best work in primary care is now focused on specialty care, especially the complex needs of elderly and disabled patients. “Various organizations have built a whole care model for those people,” Porter says.

To finance all of these primary care changes, Porter and Lee endorse the bundled payment model for a “total package of services for a defined primary care subgroup during a specific period of time, the approach most aligned with patients.”

While some healthcare organizations are moving in the right direction to improve primary care, much is lacking. Lee was even tough on his own health system. “We’ve got 65,000 employees, and the number of people whose job it is to improve the value of our care for healthy people, which is most people out there? The number is zero,” Lee says of Partners. “It’s not anyone’s job right now. Therefore, no one does it in a systematic way.”

Indeed, there is much discussion about population health, medical homes and Accountable Care Organizations with primary care physicians playing important roles. That’s nice, Porter and Lee say, but those models still fall short of the multidisciplinary, collaborative teams needed to augment primary care.

“We’re saying ‘let’s take it one step further,'” Porter says. “What are the primary care needs of different individuals?”

Porter and Lee acknowledge that their model certainly poses difficulties for small practices, but they insist small physician groups should not be excluded.

“There are a whole bunch of forces challenging the one and two doctor practice going forward,” Lee admits. “I don’t think anyone will look back and say this paper by Mike Porter and Tom Lee put them over the edge. There are ways to get physicians spread out, even in rural settings, to work together. They have to be ready to want to work together and collaborate with colleagues to improve the value of care for patients over time.”

Change must be in the offing for primary care, Lee insists. “I don’t think anyone feels like things are stable and that all (physicians) need to do is just show up for work and work as they currently are working and be OK,” Lee says. “We want to provide this strategic framework to make something happen, as opposed to fretting about it.”

Those are some of the findings from a survey of 900 practicing registered nurses by the ANA and GE Healthcare. The survey, which queried 500 nurses in the United States, 200 in the United Kingdom, and 200 in China, finds that few nurses would call their hospitals “safe.”

One of the most striking findings is the apparent chasm between the existence of hospital patient safety programs and their perceived effectiveness. For example, 94% of nurses surveyed say that their hospitals have programs in place that promote patient safety, which on the surface is great news; these programs are probably something that the execs at these institutions brag about.

However, nurses—90% of whom consider themselves most responsible for patient safety, over physicians (69%) and patient safety officers (60%)—don’t seem enthusiastic about the effectiveness of their hospital’s patient safety programs.

Only 41% of nurses describe the hospital they work in as “safe.” Just over half of nurses (57%) believe that the patient safety programs in their hospital are effective.

Whether these programs exist doesn’t seem to affect nurses’ perceptions of patient safety as much as the factors that affect how the programs are actually put in to practice. For example, in theory, patient safety programs might rely on error reporting and discussing these errors as a team.

In practice, however, error reporting often doesn’t occur because nurses are afraid they’ll be penalized for making mistakes. The survey found that although 90% of nurses say it’s important to have a culture where nurses are not penalized for reporting errors or near misses, 59% agree that nurses often hold back reporting patient errors in fear of punishment. Most nurses (62%) say the same about reporting near-misses.

Another key component of patient safety is open communication between nurses and their peers (and their leaders); nurses and physicians; and hospitals and patients.

But again, nurses identify a gap between theory and practice. Despite the prevalence of patient safety programs—and the communication that those programs presumably encourage—just 37% of nurses rated their hospital as excellent at communication with the patient. Even fewer nurses (31%) say their hospital is excellent at communication between staff.

For example, 33% of nurses said that that “poor communication among nurses at handoff” is something that has increased the risk of patient safety incidences in their hospital in the past 12 months, and 31% said “poor communication with doctors” has also increased the risk of patient safety incidents.

Another area where nurses crave more communication is technology. The survey finds that 74% of nurses say that technology/software patient safety initiatives exist in their hospitals. Although 59% of nurses say that patient safety data is collected and reported, they also say that there’s no follow-up or feedback given to the nurses.

Taken as a whole, these results seem to indicate that nurse leaders need to make a greater effort to really engage bedside nurses in patient safety initiatives, from development to implementation. Nurse leaders and executives should remember what Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance, told me recently:

“There’re some incredibly creative and innovative bedside nurses in each and every organization. I’m always amazed at the ideas and the strategies that they’re even able to bring forward themselves; how to make something better.”

There is more than one way to die well, say Katherine Sleeman and Emily Collis in their article on caring for dying patients (doi:10.1136/bmj.f2174). The trouble is that far too many people die badly. Whatever your definition of a good death, dying in hospital when you would prefer to die at home, or dying in pain, distress, isolation, or uncertainty will not be part of it. Yet, as the authors explain, over half of all deaths (in the UK at least) occur in hospital, many patients die with unmet needs, and more than half of complaints referred to the Healthcare Commission are about the care of dying people. All of this is despite the growing recognition of the need for good end of life care. And of course the risk of dying badly matters not only to the person who is dying but to their relatives and friends. The authors quote Cicely Saunders, founder of the hospice movement: “how we die remains in the memory of those who live on.”

But there is good news. While modern medicine often seems to actively promote bad end of life care, doctors can do a great deal to help patients achieve a good death. Early identification of the dying phase, good communication with patients and relatives, sensible prescribing, effective management of physical symptoms, and understanding of the patient’s social, psychological, and spiritual needs must all play their part.

Sleeman and Collis have targeted their advice towards doctors in training. But clinicians at all levels of experience will benefit from reading their article. Senior doctors will, in any case, want to model the highest professionalism and humanity when dealing with dying patients. Knowing that younger doctors will be taking their cues from you provides an additional incentive.

The article usefully tackles some of the misconceptions that have dogged the Liverpool care pathway in recent months. The pathway is a framework, not a treatment, so doesn’t need formal consent, but the decision to start someone on it should be made by a multidisciplinary team and should be discussed with the patient where appropriate and always with the relatives. While on the pathway, patients should be supported to eat and drink; and if the patient’s condition improves, the pathway can be stopped.

Essential to good end of life care is the ability to recognise that a person is dying. Sadly, this is a prognostic skill that doctors are “notoriously poor at,” say the authors. But do patients need to know that they are terminally ill in order to receive good care? The same authors take part in our Head to Head debate this week, arguing that patients should be told, since this knowledge is necessary for informed decisions (doi:10.1136/bmj.f2589). But Leslie Blackwell argues against what she calls “prognostic disclosure” (doi:10.1136/bmj.f2560). This is, she says, “a failed model for medical decision making that creates more suffering than it relieves,” and “for most people the apparent choice between comfort and prolongation of life is a false one.” I’m not convinced, but I would like to hear your views.

For clarity’s sake, I define a continuous improvement culture as an environment in which we strive to improve every process, every day, with everybody involved. No improvement is too small, we don’t batch all our improvements into big projects, and anybody in the organization can be an improvement leader. For more information on this concept applied to healthcare, see Graban & Swartz’ book Healthcare Kaizen.

Anyway, in Duhigg’s book, the habit-building loop is presented. It has three components:

Trigger: this is the cue to perform a routine

Routine: this is the standard steps performed to arrive at the desired result

Reward: this is the payoff for performing the routine on-cue

When these three elements are in-place and clearly related, a craving eventually forms. This craving causes the habituated person to anticipate the reward at the trigger point, even before performing the routine. This phenomenon is the indicator of a well-formed habit (for better or for worse!).

While Duhigg’s book is about the science behind habit-forming, Rother’s book is about the habits needed to drive continuous improvement. Specifically, he emphasizes two habits (he uses the term ‘kata’):

Improvement Kata: this is a 4-step routine that helps us 1) see the ideal condition to which we strive, 2) study the current condition to see our gaps, 3) set a short-term target condition to pursue that is on the path to the ideal condition, and 4) pursue the target condition using PDSA (another 4-step routine).

Coaching Kata: this is a routine, drawing upon the Socratic Method of teaching (asking questions instead of giving answers), that is designed to reinforce the proper execution of the aforementioned Improvement Kata.

So, how do we put in place the three elements of the habit-building loop for the two kata? How do we create a craving for the kata? The routines (element #2 of the habit-building loop) are established by Rother’s book. The other two elements, triggers and rewards, are TBD for me personally. Some thoughts:

Triggers: eventually, the ideal would be that the trigger is the detection of a problem/gap/opportunity for improvement, but in the short-term, more artificial triggers may be needed (i.e. require each manager to perform one PDSA cycle per month…not a long-term solution, but can get the ball rolling in the short-term).

Rewards: eventually, the ideal would be that the reward would be the intrinsic motivators of mastery, autonomy, and purpose (see Daniel Pink’s Drive), but in the short-term, more artificial rewards may be needed (i.e. gamification: badges, achievements, recognition, compliance tracking, small gifts, etc.)

This type of habit-building is tricky business. Culture change is hard. It takes a wide range of knowledge, organizational finesse, and a lot of trust and patience on the part of senior leadership. But the payoff is huge. A culture of continuous improvement is the best, most sustainable competitive advantage available.

NICE approves eye drug for diabetes

A drug that can save the sight of people with diabetes may now be made available on the NHS in England and Wales – reversing an earlier decision.

At least 50,000 people in the UK have diabetic macular oedema which can leave people unable to read, work or drive.

In 2011, the National Institute for Health and Clinical Excellence (NICE) said ranibizumab, which is sold as Lucentis, was too expensive.

A final decision will be made in February.

Macular oedema occurs when fluid leaks from the small blood vessels in the eye.

Diabetes can trigger changes to the blood vessels leading to fluid collecting in the central part of the retina called the macular area.

Saving sightProf Carole Longson, from NICE, said the manufacturers had agreed to reduce the price which led to a review of the guidance.

“NICE is pleased to recommend ranibizumab as a treatment option for some people with visual impairment caused by diabetic macular oedema in new draft guidance.”

Clara Eaglen, eye health policy and campaigns manager at the charity RNIB, said: “We believe NICE has thrown a lifeline to the growing number of people with diabetes facing blindness.

“Currently people are needlessly losing their sight from diabetic macular oedema.”

Barbara Young, the chief executive of Diabetes UK, said: “We are delighted that NICE have reconsidered their previous decision, and that this draft guidance recommends that Lucentis is made available on the NHS, as this would mean more people with diabetes would have a better opportunity to preserve and possibly improve their vision.”

UNITED STATES OVERVIEW: 2012

America’s Health Rankings®–2012 Edition shows Vermont at the top of the list of healthiest states again this year. The state steadily rose in the rankings over the last 14 years from a ranking of 17th in 1998 to first, where it has remained for 4 consecutive years. Hawaii is ranked second this year, an improvement from ranking third in the 2011 Edition and fifth in the 2009 and 2010 Editions. Hawaii has ranked in the top 6 states every year of the index.New Hampshire is third, followed by Massachusetts and Minnesota. Mississippi and Louisiana tie for 49th as the least healthy states. Arkansas, West Virginia, and South Carolina complete the bottom 5 states.

Vermont ascended from 20th in 1990 and 1991 to the top position with sustained improvement in the last decade. Vermont’s strengths include its number one position for all health determinants combined, which includes ranking in the top 10 states for a high rate of high school graduation, a low violent crime rate, a low incidence of infectious disease, a low prevalence of low birthweight infants, high per capita public health funding, a low rate of uninsured population, and ready availability of primary care physicians. Vermont’s challenges are a high prevalence of binge drinking at 18.5 percent of the adult population, a moderate occupational fatalities rate at 3.9 deaths per 100,000 workers, and a moderately high cancer death rate at 185.0 deaths per 100,000 population.

Mississippi and Louisiana are tied for 49th and rank last this year. These 2 states have been in the bottom 3 states since the 1990 Edition.

Mississippi ranks well for a low prevalence of binge drinking and a low violent crime rate. It ranks in the bottom 5 states on 12 of the 24 measures including a high prevalence of obesity, a high prevalence of a sedentary lifestyle, a low high school graduation rate, limited availability of primary care physicians, a high prevalence of low birthweight infants, and a high prevalence of diabetes. Mississippi ranks 49th for all health determinants combined, so its overall ranking is unlikely to change significantly in the near future.

Louisiana ranks well for a low prevalence of binge drinking and a high rate of childhood immunizations. It ranks in the bottom 5 states on 13 of the 24 measures including a high prevalence of obesity, a high rate of children in poverty, a high rate of low birthweight infants, a high prevalence of diabetes, and a high rate of cardiovascular and cancer deaths.

Every once in a while a topic comes up that takes me back to the origins of this blog. At its core, DrJohnM aims to merge the worlds of athletics, health and medicine. The glue, the secret sauce, is mastery of the obvious.

As an athlete and doctor, I get to see how both plans parallel each other.

Katie Compton is an American cyclocross champion. She dominates her races, both in the US and Europe. I have seen her race on many occasions and her prowess is more impressive when viewed in real-time as a spectator.

A friend sent me a list of Ms. Compton’s most valuable nuggets of coaching advice. They highlight basic precepts of medical practice.

Less is more. This has become the mantra of modern-day medical practice. Nearly every week, a study comes out touting the values of a less-is-more strategy. In Medicine, we seek smarter, not more, therapy. Catheter ablation of atrial fibrillation has evolved to burn less, not more. Programming of ICDs aims to shock and pace less, not more. The list goes on.

No sense beating a dead horse. Doctor-surgeon-writer Atul Gawande authored this important piece on the frequency of surgery in the last year of life. Nearly 1 in 3 elderly patients undergo in-patient surgery in the last year of their life and almost 10% have surgery in the last week of life. The intensity and amount of care that is delivered as patients near end-of-life is a huge problem in US healthcare. It’s not just a crisis of cost; it’s a crisis of humanity.

All doctors, and I guess most patients, know this. Sadly though,non-nuanced sensational talk of death panels has inhibited the conversation. The solution here is simple and obvious: at all levels, patients, doctors and policy makers, call them stakeholders if you must, need to earnestly discuss goals of care. What are the patient’s goals? Has anyone asked? Has the truth been told?

Same as we always do, don’t mess it up. This one relates well to the electrophysiology lab. Over a decade and half, we have developed a repetitive plan. The team knows it; the doctor knows it, and it works. We have years of good results to show for it. Outsiders have studied it and they too validate the process. We try not to deviate from what works. Sure, new technologies come and we keep an open mind to them, but the basic plan stays the same.

As an aside, I think this tenet is why many doctors are disturbed by the forced adaptation of electronic medical records. During our initiation of EMR months ago, a flustered colleague remarked that it would be a bad time to be a sick patient. It’s because the un-Apple-like health EMR system had caregivers off the plan that works. It’s better now, but still, EMR in its current form ‘messes up’ what has worked for centuries—human-to-human time with the patient.

A good coach takes a great athlete and doesn’t screw them up. There are rules in medicine. You can’t make an asymptomatic person feel better. Do no harm. This is at the heart of the debate on screening and doing things to people without symptoms. In the world of heart rhythm medicine, this rule comes up frequently: how much burden should we ask a well-patient to accept in the form of therapy for something that hasn’t happened yet. Think implanting an ICD in a patient without arrhythmia or treating a patient with asymptomatic atrial fibrillation with a potent medication. These are important issues to think about. Don’t screw up the patient. Do no harm. Sometimes the right answer is to treat; but not always.